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Andrzej Frycz Modrzewski Krakow University
ul. Gustawa Herlinga-Grudzińskiego 1, 30-705 Kraków
..............................
(submission date)
.................................
(signature of Recruitment Officer)
UNIVERSITY APPLICATION FORM
FIELD OF STUDY:
SPECIALISATION:
COURSE LEVEL:
COURSE FORM:
ACADEMIC SEMESTER:
INTERNATIONAL RELATIONS
International Tourism
first degree studies
daytime / extramural**
2011/2012 summer / winter**
** mark the right one
1. PERSONAL DATA:
first name
middle name
surname
former last name (if different)
father’s name
mother’s name
Personal Identity Number
year
month
day
place of birth
2. SEX, MARITAL STATUS, NATIONALITY, CITIZENSHIP:
F/M*
sex
marital status
* mark the right one
nationality
citizenship
3. ID CARD AND PASSPORT:
ID series
number
Issued by
passport
4. SECONDARY SCHOOL DIPLOMA
–
Diploma number
–
Issue date yyyy-mm-dd
School leaving year
School name
School name
Secondary school
type:
city
High School, Specialized Secondary School, Technical High School,
other:............................
5. PERMANENT HOME ADDRESS
city / town: [ ] village: [ ]
street
province
–
Town / city / village
postcode
post
6.MAILING ADDRESS:
1/3
Street
province
–
Town / city / village
postcode
post
7. CONTACT DETAILS:
e-mail (in CAPITAL LETTERS)
landline phone
mobile phone
8.MILITARY SERVICE:
RECRUIT SERVICE OFFICE
city / town
Series and number
A /B /D /E
przedpoborowy / conscript / deployed to reserve / zwolniony
/ professional officer
Military category.
stosunek do służby wojskowej
9. CERTIFIED DISABILITY: (* mark the right one)
I - mild/ II - moderate/ III - distinct*
vision / hearing / movement*
level of disability
kind of disability
10. SOURCE OF INCOME: (* mark the right one)
own business activity/ own job/ parent’s jobs/ farm/ allowance/
pension/other*............................................................
Source of income
11. IN CASE OF RESIGNATION BEFORE ENROLLMENT:
(*mark the right one)
I ask for the documents to be sent to the mailing address above (registered delivery letter)*
I will collect the documents form the Recruitment Department in person*
I consent to the processing of my personal data, including sensitive data, if so required by the recruitment and studies’ procedures,
especially by the ProAcademia system designed to manage the process of documentation of studies in accordance with the Law of
29 August 1997 on Personal data Protection, Dz.U. Nr101, poz.926 as amended.
I have been informed on the following issues:
1)
I hereby authorize Andrzej Frycz Modrzewski Krakow University, located in Krakow, Herlinga Grudzińskiego 1 Street to
administer my personal data;
2)
my personal data can be accessed to other subjects only in law; or in order to fulfill requirements of the studies, including
conducting online classes;
3)
personal data submission is voluntary; however, the refusal shall be understood as inability to qualify for the studies;
4)
I recognize that I am fully entitled to access and modify my personal data;
5)
in case of non-acceptance for the studies, my personal data shall be deleted.
_____________ dnia: ________
miejscowość
czytelny podpis kandydata
data
2/3
Consent for processing personal data by Miejskie Przedsiębiorstwo Komunikacyjne S.A
In order to use e-student ID card as a media of the Cracow City Card Programme, hereinafter referred to as
the Programme
I AGREE
I REFUSE
to give consent for my personal data included in the Programme to be transferred to Miejskie
Przedsiębiorstwo Komunikacyjne S.A. by Andrzej Frycz Modrzewski Krakow University and processed by
Miejskie Przedsiębiorstwo Komunikacyjne S.A under the Data Protection Act 1997 (Dz. U. no. 133, item
133) to the extent necessary for the implementation of the Programme.
The consent includes processing of the following data necessary for the implementation of the Programme:
1)
name , surname
2)
permanent home address
3)
Personal Identity Number
4)
student's grade book number
5)
date of completion of (or resignation from) the studies
I further confirm that I have been informed on the following issues:
1) administration of the transmitted data will be passed on Miejskie Przedsiębiorstwo Komunikacyjne S.A.,
located in Kraków, Wawrzynca 13 Street
2) my personal data will be processed by MPK S.A. Krakow only to implement the Programme
3) granting consent for data transmission to MPK S.A. is voluntary; however, the refusal will be understood
as an inability to participate in the Programme
4) I recognize that I am fully entitled to access and modify my personal data.